Advent of severe mitral regurgitation in surgical ventricular restoration and ventricular septal rupture repair.

BACKGROUND: Per-procedural severe mitral regurgitation is a rare complication in concomitant surgical ventricular restoration and postinfarction ventricular septal rupture repair. It is challenging to discover the underlying etiology and adopt an appropriate strategy, in particular, in a high-risk patient. CASE PRESENTATION: Semi-emergent surgical ventricular restoration combined with ventricular septal rupture closure and coronary artery bypassing was performed in a 67-year-old male patient. Severe mitral regurgitation was detected after the weaning of cardiopulmonary bypass. Two key questions arose in the management of this condition: did the regurgitation exist previously and was dissimulated by significant left-to-right shunt, or it occurred secondarily to the Dor procedure? Which was the better management strategy, chordal-sparing mitral valve replacement or mitral plasty? We believed that severe mitral regurgitation was under-estimated pre-operatively and we performed an downsizing annuloplasty to treat mitral regurgitation. The outcomes were promising and the patient did well in follow-up. CONCLUSIONS: Our case brought out an open discussion on the etiology and therapeutic strategies of this complicated condition.

Fifteen-Year Outcomes After Valve-Sparing Aortic Root Remodelling or Exclusion of the Non-Coronary Sinus: When to Preserve the Sinuses of Valsalva?

BACKGROUND: Isolated exclusion of the non-coronary sinus (NCS) is an attractive strategy in valve-sparing aortic root surgery, which avoids the mobilisation and re-implantation of coronary ostia. However, the long-term durability of aortic valve repair and the fate of remnant sinuses of Valsalva remain unclear. METHOD: From January 2006 to December 2013, 29 patients underwent replacement of the ascending aorta extending to the NCS (group NCS) and 56 patients underwent a modified Yacoub procedure (group MY) in our centre by a single surgeon. Significant difference of preoperative parameters was observed between two groups in the presence of bicuspid aortic valve (41.4% vs 12.5%, p=0.002) and the diameter of the sinus of Valsalva (47.3±4.7 mm vs 51.5±4.9 mm, p=0.01). RESULTS: The group NCS, as compared to the group MY, was associated with significantly shorter cardiopulmonary bypass time (106.6±40.5 min vs 138.4±37.5 min, p=0.001) and aortic cross clamping time (69.0±21.8 min vs 105.4±27.8 min, p<0.01). The mean follow-up was 11.5±2.8 years. No surgical re-intervention was performed for aortopathies of the aortic root; the neo-sinus were not dilated in either groups (38.2±4.2 mm vs 34.0±4.0 mm, p<0.01). The 10-year freedom from aortic valve-related re-operation was estimated to be 96.6±3.4% and 94.5±3.1% (p=0.58), and the cumulative 10-year survival rates were 95.2±4.6% and 85.6±4.7% (p=0.61) in the group NCS and the group MY, respectively. CONCLUSIONS: Aortic valve-sparing isolated NCS replacement can be safely performed in selected patients; its early outcomes, overall survival and long-term freedom from aortic valve-related or aortopathy-related re-intervention were comparable to those obtained with the Yacoub procedure.

Fifteen-Year Outcomes Following Valve-Sparing Aortic Root Replacement in Elderly Patients.

BACKGROUND: Valve-sparing aortic root replacement (VSRR) techniques have several advantages such as preservation of physiological haemodynamics of the native aortic valve and avoidance of prosthetic valve-related complications. However, VSRR procedures are generally performed in young patients and the long-term results in elderly patients (≥65 years) are scarce. METHODS: Fifty-six (56) consecutive patients underwent VSRR surgery by a single surgeon at the current centre between January 2006 and December 2013; a modified "remodelling technique" was typically performed. The mean age was 58.86±12.5 years; Marfan syndrome and bicuspid aortic valve were both present in six patients (10.7%); 38 patients (67.8%) presented with greater than moderate aortic regurgitation; and 17 patients (30.4%) were in New York Heart Association (NYHA) class III before surgery. They were divided into two groups according to their ages receiving VSRR surgery: Group E (elderly patients aged ≥65 years, n=24) and Group Y (young patients aged <65 years, n=32). The primary outcomes were aortic valve-related reoperation, cardiovascular reoperation, all-cause mortality, and functional status. RESULTS: One (1) patient in Group E was converted to aortic valve replacement as a result of a failed aortic valve repair. No perioperative mortality was observed. The mean follow-up was 11.5±2.9 years. Aortic valve-related reoperation was noted in two patients of each group (one with endocarditis, one with severe aortic regurgitation). Cardiovascular reoperations were observed in three and six patients, and all-cause deaths in seven and two patients in Group E and Group Y, respectively. The 10-year freedom from aortic valve-related reoperation was estimated to be 91.7±5.6% and 92.7±5.0% (p=0.594), the 10-year freedom from cardiovascular reoperation was 86.4±7.3% and 81.1±7.7% (p=0.781), and the cumulative 10-year survival rates were 74.0±9.2% and 93.8±4.3% (p=0.018) in Group E and Group Y, respectively. During follow-up, 6.7% of patients were in NYHA class III and 6.4% of patients developed moderate-to-severe aortic regurgitation. Cox regression analysis failed to identify predictors for primary outcomes. CONCLUSION: Valve-sparing aortic root replacement can safely be performed in elderly patients with low early mortality and satisfactory long-term freedom from aortic valve-related and cardiovascular re-intervention.

Assessment of bedside lower limb angiography combined with continuous NIRS monitoring for the detection of lower limb complications of VA-ECMO: an observational monocentric study.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03910062.

Coronary computed tomography angiography for heart team decision-making in multivessel coronary artery disease.

Aims: Coronary computed tomography angiography (CTA) has emerged as a non-invasive diagnostic method for patients with suspected coronary artery disease, but its usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the agreement between separate heart teams on treatment decision-making based on either coronary CTA or conventional angiography. Methods and results: Separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist were randomized to assess the coronary artery disease with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel coronary artery disease. Each heart team, blinded for the other imaging modality, quantified the anatomical complexity using the SYNTAX score and integrated clinical information using the SYNTAX Score II to provide a treatment recommendations based on mortality prediction at 4 years: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or equipoise between CABG and PCI. The primary endpoint was the agreement between heart teams on the revascularization strategy. The secondary endpoint was the impact of fractional flow reserve derived from coronary CTA (FFRCT) on treatment decision and procedural planning. Overall, 223 patients were included. A treatment recommendation of CABG was made in 28% of the cases with coronary CTA and in 26% with conventional angiography. The agreement concerning treatment decision between coronary CTA and conventional angiography was high (Cohen's kappa 0.82, 95% confidence interval 0.74-0.91). The heart teams agreed on the coronary segments to be revascularized in 80% of the cases. FFRCT was available for 869/1108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients. Conclusion: In patients with left main or three-vessel coronary artery disease, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography suggesting the potential feasibility of a treatment decision-making and planning based solely on this non-invasive imaging modality and clinical information. Trial registration number: NCT02813473.

Treatment of Mitral Valve Regurgitation with an Open Rigid Annuloplasty Ring.

BACKGROUND AND AIM OF THE STUDY: Annuloplasty constitutes a major operative step in the surgical treatment of degenerative mitral valve regurgitation (MR). The choice of ring structure to obtain an adequate remodeling of the mitral orifice and to respect the motion of the mitral apparatus remains the subject of debate. The study aim was to determine the clinical and echocardiographic outcome when using an open rigid ring to treat MR. METHODS: A total of 129 patients (94 men, 35 women; mean age 64.5 ± 11.7 years) was referred to the authors' institution between 1997 and 2011 for the surgical management of severe MR. Patients were implanted with a modified open rigid annuloplasty ring, and also underwent anterior and/or posterior leaflet repair. The occurrence of any major adverse cardiac and cerebrovascular event (MACCE) was considered as the primary end-point and was retrospectively collected along with echocardiographic data. RESULTS: The perioperative mortality was 1.6%. The cardiopulmonary bypass and cross-clamp times were 73.3 ± 17.1 min and 51.6 ± 13.0 min, respectively. There was one case (0.7%) of postoperative mitral systolic anterior motion. During a mean follow up period of 6.0 ± 3.1 years, 25 patients (19%) presented a MACCE. MACCE-free survival at one, five and 10 years was respectively 96.8%, 91.3%, and 61.4%. Preoperative determinants of MACCE were paroxysmal/persistent atrial fibrillation (HR 2.53; 95% CI: 1.06-6.01; p = 0.035) and age (HR 1.05; 95% CI: 1-1.09; p = 0.035). CONCLUSIONS: Mitral valve repair with an open-rigid ring offers satisfactory long-term results with a low rate of subsequent MR recurrence and reintervention. Preoperative AF is the main determinant of long-term adverse outcome.

Off-pump axillo-coronary artery bypass: a simple approach for high-risk myocardial revascularization.

We report the case of a 66-year-old male with increasing angina occurring after two previous coronary artery surgery procedures. The second operation had been complicated by severe mediastinitis necessitating surgical drainage, and sternal stabilization. Angiography revealed an occlusion of the LAD bypass with a patent LAD associated with a stenotic circumflex coronary artery. The ascending aorta was severely calcified. An off-pump axillo-LAD coronary artery bypass was safely performed in conjunction with stenting of the circumflex artery. This approach dramatically simplified the procedure and reduced the operative risk. At the 52-month follow-up, the patient is free of any angina symptoms.

Recurrent Biatrial Myxomas in Carney Complex with a Spinal Melanotic Schwannoma: Advocacy for a Rigorous Multidisciplinary Follow-Up.

A 31-year-old female patient with a previous history of Carney complex and surgical resection for cardiac myxoma and bilateral adrenalectomy at 18 years old and 10 and 11 years old, respectively, was referred to our department with a diagnosis of recurrent biatrial myxomas incidentally discovered on echography. A magnetic resonance imaging (MRI) confirmed the diagnosis of a tumor protruding into the left ventricle, and the patient underwent a surgical resection of a large left atrial mass and a right-sided atrial small tumor. Diagnosis of bilateral atrial myxomas was confirmed by histologic studies. Postoperative outcome was uneventful, and the patient was discharged at the 7th postoperative day. Few months later, she reported trivial clinical symptoms suspecting a cervical radiculopathy. MRI confirmed the presence of a compressive cervical spinal cord tumoral mass at the C2-3 level leading to perform a surgical exeresis of the tumor. Histology showed a spinal melanotic schwannoma. This case highlights the risk of unexpected ubiquitary tumor locations and the importance of a rigorous transversal multidisciplinary follow-up to prevent severe complications in patients with Carney complex.

Primary Epicardial Malt Lymphoma: A New Physiopathologic Entity Mimicking a Pericardial Compressive Syndrome.

MALT lymphoma is a non-Hodgkin lymphoma developing from B cells and is a type of marginal zone lymphoma. It can develop in any organs, but no case of primary cardiac location has yet been reported. We report the first observation of a primary epicardial MALT lymphoma mimicking a compressive pericardial syndrome. (Level of Difficulty: Advanced.).

Feasibility of planning coronary artery bypass grafting based only on coronary computed tomography angiography and CT-derived fractional flow reserve: a pilot survey of the surgeons involved in the randomized SYNTAX III Revolution trial.

OBJECTIVES: Invasive coronary angiography has been the preferred diagnostic method to guide the decision-making process between coronary artery bypass grafting (CABG) and percutaneous coronary intervention and plan a surgical revascularization procedure. Guidelines recommend a heart team approach and assessment of coronary artery disease (CAD) complexity, objectively quantified by the anatomical SYNTAX score. Coronary computed tomography angiography (CCTA) and CT-derived fractional flow reserve (FFRCT) are emerging technologies in the diagnosis of stable CAD. In this study, data from patients with left main or 3-vessel CAD who underwent CABG were evaluated to assess the feasibility of developing a surgical plan based on CCTA integrated with FFRCT. The primary objective was to assess the theoretical feasibility of surgical decision-making and treatment planning based only on non-invasive imaging. METHODS: This study represents a survey of surgeons involved in the SYNTAX III Revolution trial. In this trial, heart teams were randomized to make treatment decisions using CTA. CCTAs and FFRCT results of 20 patients were presented to 5 cardiac surgeons. RESULTS: Surgical treatment decision-making based on CCTA with FFRCT was considered feasible by a panel of surgeons in 84% of the cases with an excellent agreement on the number of anastomoses to be made in each patient (intraclass correlation coefficient 0.77, 95% confidence interval 0.35-0.96). CONCLUSIONS: Using non-invasive imaging only in patients with left main or 3-vessel CAD, an excellent agreement on treatment planning and the number of anastomoses was found among cardiac surgeons. Thus, CABG planning based on non-invasive imaging appears feasible. Further investigation is warranted to determine the safety and feasibility in clinical practice.

[Long-term outcome of surgical angioplasty of left main coronary artery].

OBJECTIVE: To assess long-term outcome of coronary artery diseased patients undergone the surgical angioplasty of left main coronary artery. METHODS: From September 1983 to December 2004, 162 patients were operated on for left main coronary artery stenosis with surgical angioplasty. The data were retrospectively analyzed. Operative death associated factors were evaluated with univariate analysis, and long-term survival was estimated by Kaplan-Meier analysis. RESULTS: The in-hospital mortality was 8% for all the patients but only 5.1% for the patients with simple left main coronary artery stenosis. A significant drop of operative mortality was noted in the later era of treatment (1983 to 1994 vs. 1994 to 2004). The operative death was more likely associated with no-isolated left main coronary artery pathologic feature and the urgency of surgery. An average of 102 (8 to 264) months' follow-up was completed in 95% of discharged patients. Coronary event occurred in 42 patients in the follow-up period and it was mortal for 9 cases. The overall long-term survival was 81% at 10 years and 52% at 20 years. The coronary event-free survival was 77% at 10 years and 41% at 20 years. CONCLUSIONS: Surgical angioplasty of left main coronary artery could produce excellent long-term outcome with acceptable per-operative mortality in left main coronary artery stenosis patients. This technique should deserve an important place in therapeutic options for this cohort of patients.

Development of a porcine beating-heart model of self-myocardial retroperfusion: evaluation of hemodynamic and cardiac responses to ischemia and clinical applications.

BACKGROUND: Retrograde perfusion into the coronary sinus is used to deliver cardioplegia. We developed an in-vivo porcine beating-heart model of self-myocardial retroperfusion (SMR) using the venous route to supply myocardial oxygenation and sought to assess hemodynamic and cardiac responses triggered by SMR before and after a prolonged occlusion of the LAD. METHODS: A bypass-line between the ascending aorta and the coronary sinus was made to perform a selective retrograde perfusion of the great cardiac vein with oxygenated blood (SMR). A Control group (N.=6) was assigned to collect baseline data, and an SMR group (N.=6) was dedicated to undergo SMR with occlusion of LAD for 240 minutes. Cardiac output (CO), maximal pressure in the LV (Pmax in-LV), stroke volume (SV), left ventricular ejection fraction (LVEF), diastolic durations, heart rate, and arterial systemic pressure were evaluated with conductance catheters for the following periods: basal (before SMR), SMR with patent LAD, and SMR with occluded LAD. In order to assess peripheral perfusion, patterns of sublingual microcirculation were analyzed. At the end of the procedures, the hearts were harvested for histology. RESULTS: Echographic LVEF evaluation was affected by sternotomy, but conductance catheter evaluation was not. Following pericardiotomy, CO decreased by 7.51% (P<0.05). SMR with patent LAD showed inotropic properties with improvements in CO, SV, Pmax in-LV and LVEF (P<0.0001). Following LAD occlusion, SMR supplied myocardial oxygenation with hemodynamic compensation and preserved the peripheral perfusion. Histology confirmed no signs of infarct. CONCLUSIONS: SMR showed capacities to produce inotropic effects and protect against ischemia, opening interesting perspectives.

Improving Patient Selection for Refractory Out of Hospital Cardiac Arrest Treated with Extracorporeal Life Support.

BACKGROUND: Despite recent management improvement, including Extracorporeal Life Support (ECLS), refractory out of hospital cardiac arrest (ROHCA) survival remains dramatically low. METHODS: We assessed an innovative strategy (Out of hoSpital Cardiac ARrest-ExtraCorporeal Life Support-"OSCAR-ECLS") to optimize access to ECLS of ROHCA patients and reduce the delay between recognition and ECLS implantation. METHODS: This study, conducted in a tertiary teaching hospital, compared the survival and delay times of ROHCA patients treated by ECLS before and after OSCAR-ECLS implementation. This procedure included an early recognition of ROHCA 10 min after initiation of advanced cardiopulmonary resuscitation; the optimization of patient selection and reduction in time from collapse to ECLS initiation. RESULTS: Fourteen patients before and 32 patients after OSCAR-ECLS implementation were identified between 2013 and 2016. Time to ECLS initiation was 99 (90-107) min before OSCAR-ECLS vs. 80 (65-94) min during the OSCAR-ECLS period (P = 0.0007), mostly due to a reduction in time spent on site: 48 (40.0-54.0) min vs. 24 (20.0-28.0) min (P = 0.0001). Survival at hospital discharge was 7% (1/14) before OSCAR-ECLS and 25% (8/32) during the OSCAR-ECLS period (P = 0.20). Only one patient survived with a Glasgow Pittsburgh Cerebral Performance Category (CPC) score = 1 before the OSCAR-ECLS procedure while during the OSCAR-ECLS procedure, eight patients (25%) survived, six with a CPC score = 1, one with a CPC score = 2, and one with a CPC score = 3. CONCLUSIONS: The use of a new paradigm of ROHCA dramatically shortened the time to ECLS initiation by reducing the time spent on site by more than 20 min. Survival improved from 7% to 25% after implementation of OSCAR-ECLS.

Moderate Hypothermia Improves Cardiac and Vascular Function in a Pig Model of Ischemic Cardiogenic Shock Treated With Veno-Arterial ECMO.

Cardiogenic shock (CS) patients treated with extracorporeal membrane oxygenation (ECMO) have severe cardiac failure, associated with ischemia-reperfusion. The use of moderate hypothermia during ischemia-reperfusion syndrome is supported by experimental data. We therefore studied the effects of moderate hypothermia on cardiac and vascular function in pig ischemic CS treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). CS was induced in 12 anesthetized pigs by coronary ligation. After 1 h of CS, VA-ECMO was initiated and pigs were randomized to normothermia (38°C) or moderate hypothermia (34°C) during 8 h. Intrinsic cardiac function was measured using a left ventricular conductance catheter. At the end of the experiment, tissues were harvested for Western blotting. ECMO associated with norepinephrine infusion and volume resuscitation increased mean arterial pressure, mixed venous oxygen saturation as well as carotid, renal, and coronary blood flow without any differences between normothermia and hypothermia. Hypothermia was associated with less fluid and less norepinephrine infusion, lower lactate level, and higher urinary output. Vascular reactivity was superior in hypothermia comparatively to normothermia as expressed using norepinephrine dose-response curves. Pressure development during isovolumic contraction, left ventricular ejection fraction, and prerecruitable stroke work index were higher in the hypothermia group. There were no differences between normothermia and hypothermia with regard to carotid and mesenteric protein expression for iNOs, eNOS, and phospho AKt/AKt measured at the end of the experimentation. The incidence of surgical bleeding and coagulation disorders was the same in both groups. In conclusion, moderate and rapid hypothermia improves hemodynamics and cardiac and vascular function in a pig model of ischemic CS treated with ECMO.

Proof of Concept of an Endoscopic Sutureless Valve Sizer.

OBJECTIVE: In this paper, we present an endoscopic expandable sizer conceived to allow thoracoscopic aortic valve replacement with a sutureless prosthesis using a dynamic sizing of the aortic annulus. METHODS: Ten aortic torsos were prepared using a five-trocar thoracoscopic setting. Once the aortotomy was performed and the aortic valve leaflets removed, the technical feasibility of the endoscopic sizing (introduction into the trocar, expansion into the aortic annulus, determination of the valve size, and retraction) with the device was assessed. In case of successful thoracoscopic sizing, endoscopic implantation of a sutureless valve (five LivaNova Perceval prosthesis and five Medtronic 3f Enable bioprosthesis) was performed. Before ascending aorta closure, we assessed the appropriate sealing of the bioprosthesis in the native annulus with camera visualization and a nerve hook inspection. RESULTS: All the 10 endoscopic sizings were technically feasible. The scheduled aortic sutureless valve implantations were successfully performed. In all cases, fitting and placement of the sutureless bioprosthesis in the flaccid heart was satisfactory, with no paraprosthetic leakage detectable by the nerve hook. CONCLUSIONS: The use of the endoscopic expandable sizer is technically possible. In this early-stage test in the flaccid heart, selection of the valve size was satisfactory during thoracoscopic sutureless aortic bioprosthesis implantation. Further laboratory evaluation with fluid dynamics (aortic root pressurization) will be performed before a clinical study is started.

A comparison of conventional surgery, transcatheter aortic valve replacement, and sutureless valves in "real-world" patients with aortic stenosis and intermediate- to high-risk profile.

OBJECTIVE: We sought to investigate the clinical outcomes of patients with isolated severe aortic stenosis and an intermediate- to high-risk profile treated by means of conventional surgery (surgical aortic valve replacement), sutureless valve implantation, or transcatheter aortic valve replacement in a multicenter evaluation. METHODS: Among 991 consecutive patients with isolated severe aortic stenosis and an intermediate- to high-risk profile (Society of Thoracic Surgeons score >4 and logistic European System for Cardiac Operative Risk Evaluation I >10), a propensity score analysis was performed on the basis of the therapeutic strategy: surgical aortic valve replacement (n = 204), sutureless valve implantation (n = 204), and transcatheter aortic valve replacement (n = 204). Primary end points were 30-day mortality and overall survival at 24-month follow-up; the secondary end point was survival free from a composite end point of major adverse cardiac events (defined as cardiac-related mortality, myocardial infarction, cerebrovascular accidents, and major hemorrhagic events) and periprosthetic regurgitation greater than 2. RESULTS: Thirty-day mortality was significantly higher in the transcatheter aortic valve replacement group (surgical aortic valve replacement = 3.4% vs sutureless = 5.8% vs transcatheter aortic valve replacement = 9.8%; P = .005). The incidence of postprocedural was 3.9% in asurgical aortic valve replacement vs 9.8% in sutureless vs 14.7% in transcatheter aortic valve replacement (P< .001) and peripheral vascular complications occurred in 0% of surgicalaortic valve replacement vs 0% of sutureless vs 9.8% transcatheter aortic valve replacement (P< .001). At 24-month follow-up, overall survival (surgical aortic valve replacement = 91.3% ± 2.4% vs sutureless = 94.9% ± 2.1% vs transcatheter aortic valve replacement = 79.5% ± 4.3%; P < .001) and survival free from the composite end point of major adverse cardiovascular events and periprosthetic regurgitation were significantly better in patients undergoing surgical aortic valve replacement and sutureless valve implantation than in patients undergoing transcatheter aortic valve replacement (surgical aortic valve replacement = 92.6% ± 2.3% vs sutureless = 96% ± 1.8% vs transcatheter aortic valve replacement = 77.1% ± 4.2%; P < .001). Multivariate Cox regression analysis identified transcatheter aortic valve replacement as an independent risk factor for overall mortality hazard ratio (hazard ratio, 2.5; confidence interval, 1.1-4.2; P = .018). CONCLUSIONS: The use of transcatheter aortic valve replacement in patients with an intermediate- to high-risk profile was associated with a significantly higher incidence of perioperative complications and decreased survival at short- and mid-term when compared with conventional surgery and sutureless valve implantation.

Failure of Marfan anatomic criteria to predict risk of aortic dissection in Turner syndrome: necessity of specific adjusted risk thresholds.

Patients with Turner syndrome are prompt to develop spontaneous acute aortic dissection following insidious aortic dilatation, with abnormal cardiovascular anatomy and consequently require specific guidelines for regular surveillance since they represent a subset of high-risk young patients. We report a rare and uncommon case of spontaneous acute aortic dissection in a 48-year old female patient with Turner syndrome who was not apparently eligible for a prophylactic surgery. A CT scan showed a Stanford type A aortic dissection and was urgently referred for surgical management. We operated on the patient under deep hypothermia (18°C) and circulatory arrest with a retrograde cerebroplegia as the primary entry tear was located in the arch. The postoperative course was uneventful and the patient was discharged at the eighth postoperative day. Following description of this case, special attention was paid to determine predisposing risk factors for aortic dissection to be specifically adjusted to TS patients.